How depressed is urban India?

The shocking story of the Behl sisters — who shut themselves in and starved for months, one to death, before their condition was discovered — is a reminder of the cost of loving and living in the urban jungle. Loneliness, warn experts, is emerging as a major threat to mental health. Sanchita Sharma writes.

The odds of you being depressed are high if you work long hours, socialise only on Facebook and have little time for or no family. The loneliness of living and loving in the urban jungle among other self-absorbed millions mindlessly doing exactly the same, is crowding psychiatric clinics and making bestsellers out of antidepressant drugs.

The bizarre story of the Behl sisters — who starved themselves for months, one to death, before their neighbours noticed they hadn't stepped out of their Noida home since October last year —reflects the gloom that has gripped urban consciousness. Loneliness, say mental health experts, is a bigger stressor than work or domestic stress simply because it offers no vent for negative emotions, leading to a clutch of symptoms that include feeling low, insomnia, eating little too little or too much, and losing interest in things around you. It drives people further into themselves, with the finale being a nervous breakdown or a tryst with therapy and anti-depressant medication.

"Families are getting smaller and increasingly, neighbours and friends want to intrude and take up your time. It's a very typical urban phenomenon that causes emotional isolation and eventually takes a toll on your mind," says Dr Rajesh Sagar, associate professor of psychiatry at the All India Institute of Medical Sciences.

Social networking sites clearly do not offer the same support as real people, as evident by the case of UK's Simone Back. "Took all my pills be dead soon so bye bye every one." This was the last Facebook update posted by the depressed charity worker before she killed herself on Christmas day last year. Back had 1,082 facebook friends, none of who thought of calling her or dropping by to find out what was wrong.

Troubled Headcount A staggering 7% of India's population suffers from some form of psychological problem, with close to 3% needing active treatment, shows data from the National Institute of Mental Health & Neuro Sciences.

Depression is a term used to describe a wide range of symptoms (see box), but everyone goes through highs and lows, treatment should be sought if the symptoms become chronic, recurrent or frequent. At worst, depression leads to suicide, which is responsible for 8.5 lakhs deaths globally, shows World Health Organisation data.

The latest National Crime Records Bureau recorded 1,27,151 self-inflicted deaths in India in 2009 as compared to 1,13,914 in 2005. Simply put, this means 15 people kill themselves every hour, of which one in every three suicides is committed by young people aged 15-29. Suicides are more common in men —223 men kill themselves every day compared to 125 women, though more women attempt suicide unsuccessfully.

Among the metros, Bangalore has the most suicides at 2,167, followed by Chennai with 1,412, Delhi with 1,215 and Mumbai with 1,051 suicides.

Starting youngPreschoolars in Delhi are now being diagnosed and prescribed drugs for depression, with children as young as three ending up on the counselling couch. The big hurdle in diagnosing depression in little children is that the symptoms vary widely, with prolonged sadness — the qualifier of depression in adults — not being present in most children at all.

The more common symptoms among children are listlessness and anhedonia, the medical word used to describe an inability to enjoy experiences that give others pleasure. In still younger children, the signs of depression are crying, clinging to parents, irritability or aggression.

The Indian Council Of Medical Research reports show that 12.8% adolescents have psychiatric problems. Of these, about 3-4% have clinical depression. During adolescence, girls are twice more likely to develop depression as they undergo more hormonal changes at the age. Children with anxiety disorders, ADHD (attention deficit hyperactivity disorder) or OCD (obsessive compulsive disorder) and social dysfunction are more likely to suffer bouts of depression.

"With pressure to compete starting from the time you start school, one-third of the 25 new patients I treat every week are adolescents and teenagers," says Dr Himanshu Saxena, a senior psychiatrist with Fortis Shalimar Bagh and Jaipur Golden Hospital.

Happy pills India is about a decade behind this global trend of indiscriminately popping prescription antidepressants made infamous by the British who managed to pollute the country's ground and river water with Prozac to such as extent that traces of the drug were found in the drinking water supply.

In India, the market for antidepressants stands at Rs 475 core, growing at 17% annually. Anti-psychotics used to treat schizophrenia but often wrongly prescribed for bipolar disorder and anxiety, are also growing at 14%, with the current market worth being Rs 193 crore, reports ORG IMS, which offers pharma industry data.

"Most prescriptions are not evidence based and psychiatrists obligingly prescribe antidepressants such as Escitalopram, which is a known trigger of diabetes. Wrong prescriptions, coupled with unregulated over-the-counter sale of prescription drugs have a country high on drug-induced happiness," says drug-expert Dr C. M Gulati, editor of medical journal Monthly Index of Medical Specialities.

The rising sales reflect a global trend. The Pharmacoepidemiology and Drug Safety reports that prescription of anti-psychotic drugs in the US doubled over the past 15 years, even though side effects of long-term use include diabetes, weight gain, sexual dysfunction and heart disease.

Glad to be backThe good news, says Dr Nimesh Desai, director, Institute of Human Behaviour and Allied Sciences, is that most depressions can be easily managed at home. "Freudian ideas of psychoanalysis are now extinct like dinosaurs. If you are depressed at 40, I don't need to go into why you were depressed at age 4. Dr Aaron Beck's cognitive triad for depression is more relevant, where the aim is to change the patient's negative view of self, of the world and the future with or without drugs," says Dr Desai.

Counselling, coupled with antidepressants such as selective serotonin reuptake inhibitors (SSRIs), is effective in treating severe and persistent depression. Like the 15-year-old engineering aspirant, who ended up with symptoms of severe depression. "He put in long hours but could not make the cut in a category of achievers, but a combination of counselling and anti-depressants helped him bounce back. He's made it to a good engineering college," says Dr Saxena.

Psychologists say there is a strong statistical association between how much in control of your life you feel and the risk of depression. Feeling you have lost control makes you chronically stressed and puts you at risk of psychological problems. Given the shocking statistics, tracking mood changes among your family and friends may be a good idea. Once the problem is identified, all you have to do is ask them to choose their treatment modality, be it medical prescriptions or real-time social networking.